Claire E. Holland

A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come?

HIV‐related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission

Male sex workers who sell or exchange sex for money or goods encompass a very diverse population across and within countries worldwide. Information characterising their practices, contexts where they live, and their needs is limited, because these individuals are generally included as a subset of larger studies focused on gay men and other men who have sex with men (MSM) or even female sex workers. Male sex workers, irrespective of their sexual orientation, mostly offer sex to men and rarely identify as sex workers, using local or international terms instead. Growing evidence indicates a sustained or increasing burden of HIV among some male sex workers within the context of the slowing global HIV pandemic. Several synergistic facilitators could be potentiating HIV acquisition and transmission among male sex workers, including biological, behavioural, and structural determinants. Criminalisation and intersectional stigmas of same-sex practices, commercial sex, and HIV all augment risk for HIV and sexually transmitted infections among male sex workers and reduce the likelihood of these people accessing essential services. These contexts, taken together with complex sexual networks among male sex workers, define this group as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Evidence-based and human rights-affirming services dedicated specifically to male sex workers are needed to improve health outcomes for these men and the people within their sexual networks.

Epidemiology of HIV among female sex workers, their clients, men who have sex with men and people who inject drugs in West and Central Africa

The West and Central Africa (WCA) sub‐region is the most populous region of sub‐Saharan Africa (SSA), with an estimated population of 356 million living in 24 countries. The HIV epidemic in WCA appears to have distinct dynamics compared to the rest of SSA, being more concentrated among key populations such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and clients of FSWs. To explore the epidemiology of HIV in the region, a systematic review of HIV literature among key populations in WCA was conducted since the onset of the HIV epidemic.

The epidemiology of HIV among men who have sex with men in countries with generalized HIV epidemics

Purpose of reviewKey populations at high risk for HIV acquisition and transmission, such as MSM, have long been identified as essential subpopulations for epidemiological surveillance of the HIV epidemic. However, surveillance systems in the context of generalized and widespread HIV epidemics have traditionally excluded these men. Recent findingsEmerging and consistent data highlight the disproportionate burden of HIV among MSM that exists when compared with other men of reproductive age across countries with generalized epidemics. Correlates of prevalent HIV infection include individual-level determinants of HIV acquisition and transmission similar to that found in concentrated HIV epidemics and community-level structural factors, such as stigma, being blackmailed, and history of homophobic abuse. HIV incidence was only available from two countries (Kenya, Thailand) with generalized HIV epidemics, but in both settings was an order of magnitude higher than that of other populations. SummaryThe data presented here suggest that the dynamics of HIV infection among men are more similar across the world than they are different. Many HIV epidemics among average-risk reproductive age adults are slowing across both generalized and concentrated settings. It is in this context that high HIV incidence is observed among MSM, especially young MSM. This trend suggests a change in the trajectory of these HIV epidemics, a change that we may miss if we continue to understudy these populations based on unproved and dated assumptions.

Enhancing benefits or increasing harms: Community responses for HIV among men who have sex with men transgender women female sex workers and people who inject drugs.

Abstract:Studies completed over the past 15 years have consistently demonstrated the importance of community-level determinants in potentiating or mitigating risks for the acquisition and transmission of HIV. Structural determinants are especially important in mediating HIV risk among key populations, including men who have sex with men, people who inject drugs, sex workers of all genders, and transgender women. The objective of this systematic review was to synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations. The results of the review suggest that although health communication programs represent community-level strategies that have demonstrated the effectiveness in increasing the uptake of HIV testing and decreasing the experienced stigma among people living with HIV, there are limited studies focused on key populations in low- and middle-income settings. Moreover, interpretation from the 22 studies that met inclusion and exclusion criteria reinforce the importance of the continued measurement of community-level determinants of HIV risks and of the innovation in tools to effectively address these risks as components of the next generation of the HIV response. Consequently, the next generation of effective HIV prevention science research must improve our understanding of the multiple levels of HIV risk factors, while programming for key populations must address each of these risk levels. Failure to do so will cost lives, harm communities, and undermine the gains of the HIV response.

Antiretroviral treatment coverage for men who have sex with men and female sex workers living with HIV in Cameroon.

Background:Men who have sex with men (MSM) and female sex workers (FSW) are more likely to be living with HIV and experience difficulty accessing HIV health services due to stigma and discrimination. Antiretroviral treatment and sustained viral suppression among individuals living with HIV is the last step in the continuum of HIV care, which has been shown to improve health outcomes and decrease the risk of onward transmission of HIV. Methods:To calculate the numerator and denominator for antiretroviral therapy (ART) coverage estimates among MSM and FSW living with HIV, the Priority Locations for AIDS Control Efforts methods were modified to include individual quantitative interviews, health service assessment and mapping, and size estimation in 7 cities in Cameroon. MSM and FSW were recruited using peer referral and venue-based sampling. The numerator was calculated from interviews with MSM and FSW. Population size estimation of MSM and FSW was used to determine the denominator. Results:Antiretroviral coverage varied by site from 0% to 25% among HIV infected MSM and FSW. ART provision to the general population was reported at a significantly greater proportion of HIV health centers (56.5%) than ART provision to MSM and FSW populations (13.2%). Conclusions:The majority of MSM and FSW living with HIV and eligible for treatment in Cameroon are not connected to ART care. Additionally, ART provision for MSM and FSW at HIV health centers is insufficient. Characterizing effective strategies to reach optimal levels of engagement in the continuum of HIV care among MSM and FSW is essential for an AIDS-free generation for Cameroon.

Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study

Background Female sex workers (FSWs) are disproportionately affected by HIV, even in the context of broadly generalised HIV epidemics such as South Africa. This has been observed in spite of the individual and population-level benefits of HIV treatment. We characterise the HIV care cascade among FSWs and relationships with antiretroviral therapy (ART) use. Methods FSWs ≥18 years were recruited through respondent-driven sampling into a cross-sectional study in Port Elizabeth, South Africa. Participants completed questionnaires and received HIV and syphilis testing; CD4 counts were assessed among women living with HIV. Engagement in the HIV care cascade is described, and correlates of self-reported ART use among treatment-eligible previously diagnosed FSWs were estimated using robust Poisson regression. Results Between October 2014 and April 2015, 410 FSWs participated in study activities. Overall, 261/410 were living with HIV (respondent-driven sampling-weighted prevalence 61.5% (95% bootstrapped CI 54.1% to 68.0%)). Prior diagnosis of HIV was relatively high (214/261, 82%); however, ART coverage among FSWs living with HIV was 39% (102/261). In multivariate analyses, FSWs were less likely to be on ART if they had not disclosed their HIV status to non-paying partners (adjusted prevalence ratio (aPR) 0.43, 95% CI 0.22 to 0.86, where the reference is FSWs without non-paying partners), and also if they engaged in mobile healthcare services (aPR 0.71, 95% CI 0.57 to 0.89). Conclusions HIV testing and awareness of HIV status were high, but substantial losses in the cascade occur at treatment initiation. Given that FSWs engaged in mobile HIV testing and peer education programmes have unmet HIV treatment needs, models of decentralised treatment provision such as mobile-based ART care should be evaluated.

Access to HIV Services at Non-Governmental and Community-Based Organizations among Men Who Have Sex with Men (MSM) in Cameroon: An Integrated Biological and Behavioral Surveillance Analysis.

Background Men who have sex with men (MSM) are more likely to be living with HIV than other adult men in low- and middle-income countries. MSM experience barriers to accessing HIV services including a lack of available specialized care, and community-level stigma and discrimination. This study aims to examine the uptake of HIV services at non-governmental and community-based organizations (NGOs/CBOs) to identify ways to improve coverage of HIV prevention and treatment among MSM. Methods An Integrated Biological and Behavioral Surveillance (IBBS) survey was conducted in Yaoundé and Douala, Cameroon in 2011 using the respondent driven sampling (RDS) method to recruit and interview 239 MSM in Yaoundé and 272 MSM in Douala. Results MSM in Yaoundé were statistically significantly more likely to have accessed NGO/CBO services or been reached by an outreach worker in the past 12 months if they had any STI symptoms (aOR 2.17 CI 1.02-4.59. p=0.04), or if they had a larger MSM social network (aOR 1.02 CI 1.01-1.04. p<0.01). MSM in Douala were more likely to have accessed NGO/CBO services or been reached by an outreach worker in the past 12 months if they were living with HIV (aOR 3.60 CI 1.35-9.60. p=0.01), or if they reported higher numbers of male sexual partners (aOR 1.17 CI 1.00-1.36. p=0.046). Compared to men in Douala, MSM in Yaoundé were significantly less likely to have accessed NGO/CBO services or been reached by an outreach worker in the past 12 months (aOR 0.22 CI 0 .14-0.34. p=<0.01). Conclusions With appropriate funding and resources, community-based organizations that provide care specifically for MSM can improve access to HIV prevention, treatment, and care services. Additionally, using social networks to reach MSM can connect greater numbers of the population to effective HIV interventions, which will improve health outcomes and decrease onward transmission of HIV.

Pregnancy Intentions and Safer Pregnancy Knowledge Among Female Sex Workers in Port Elizabeth, South Africa.

OBJECTIVE: To assess the association between human immunodeficiency virus (HIV) and pregnancy intentions and safer conception knowledge among female sex workers in Port Elizabeth, South Africa. METHODS: This cross-sectional study recruited female sex workers in Port Elizabeth using respondent-driven sampling and completed an interviewer-administered questionnaire alongside HIV testing and counseling. In this secondary analysis, robust Poisson regression was used to model prevalence ratios for positive fertility intentions in this cross-sectional study. Knowledge of safer conception methods by HIV status was compared using Fisher exact tests. RESULTS: Overall 391 women were represented in the analyses. More than 50% had a prior HIV diagnosis, and an additional 12% were diagnosed with HIV during the study. Approximately half (n=185) of the women reported future pregnancy intentions. In univariate analysis, a prior HIV diagnosis was negatively associated with pregnancy intentions as compared with HIV-negative women (prevalence ratio 0.68, 95% confidence interval 0.55–0.85). Only parity remained independently associated with future pregnancy intentions in multivariate regression after controlling for HIV status, age, race, relationship status, and years selling sex. Knowledge of safer conception methods such as timed sex without a condom, preexposure prophylaxis, or self-insemination was low and similar between those with and without future pregnancy plans. CONCLUSION: Pregnancy intentions did not significantly vary according to HIV status. Fertility intentions were high, however, and knowledge of safer conception methods low, suggesting a need to provide female sex workers with advice around options to conceive safely in the context of high HIV prevalence.